Formerly the mark of sailors, prison inmates and gang members, now fashion designers, photographers, perfumers and cosmetic companies have seized and leveraged this form of expression. Hollywood actors and celebrities function as high-profile ambassadors of the tattooed lifestyle, further shifting tattoos into the accepted social mainstream. Today, tattoos cover more body real estate than at any other time in history.

Let’s face it—for a growing number of folks, it’s become cool to tattoo.

This embrace of body art poses potential physical dangers that are not being adequately addressed. The combination of hair dyes and body inks poses clear public health risks, and even can be especially dangerous to cosmetology and body art practitioners because of their frequency of contact with products that may contain contaminants. Of concomitant concern to practitioners is the potential for legal exposure not adhering to recommended professional protocols.

This paper examines the dangers and risks, and specifically within the professional protocols - or lack thereof - the dangers to cosmetology and body art practitioners. It defines proper protocols and warnings, and closes with recommendations that should be heeded by (1) respective industries and (2) the consumer who engages in both hair and beauty color treatments and body art.

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Hunta: Fotolia.com

Tattoo eye make-up - Fotolia

Safety Alert—For Professionals

As of 2015, 45 million people in the U.S. have at least one tattoo (6), and 75% of women and 11% of men colored their hair. (5) (7) Authorities estimate that about 14% of American adults now have tattoos and that more than 40% of people in their 30s and 40s have tattoos. (6)

The tattoo trend is growing in every way. In addition to the burgeoning market, both the number of tattoos per body and the size of the tattoos are growing. Currently, many people want multiple tattoos with big designs covering larger areas of skin rather than the discreet butterfly or small symbols popular at the start of the tattooing craze.

There are seven key audiences to be on alert:

Estheticians using foreign-made eyelash and eyebrow dyes containing PPD.Tattoo technicians either applying permanent cosmetic tattoo make-up and traditional ink tattoos or temporary tattoos, or applying temporary henna tattoos.Home hair color consumers using retail (or professional) hair color products, including parents of youth who may be considering hair color and tattoos in combination. Consumers who have both hair color and body ink or modifications.Home/amateur tattooists.Cosmetologistswho apply hair color and personally have tattoos.Cosmetology salon owners who may be liable for not applying a standard of care to prevent injury resulting from allergic reactions that occurs in their salons. (There is also potential for legal exposure from failure to adhere to standards and protocols, but that risk is not within the purview of this paper.)

"It pays to 'Think before You Ink'." and "A Tattoo for you? Seven Key Questions to Consider." by the FDA. (9) are relevant consumer communications called for with the growth in the number of tattoo wearers and those who color their hair, the possibility of related complications grow. As "body art" continues to increase in popularity, the FDA reminds consumers about health risks associated with tattoo inks and ink kits, including bacterial contamination of tattoo inks and needles, allergic reaction to inks and infections from improper aftercare. With increasing popularity of both tattoos and hair coloring the possibility grows,(1) (2) (9) (10) (12)

Unfortunately, the health risk is either (1) largely unknown among practitioners and/or (2) practitioner protocols are not in accordance with what is known about the health risks.. Considering the rate at which cosmetology and body art procedures are growing in popularity, this situation presents a very real danger. It is easy for a cosmetology professional to think "I know what I am doing. I have used this product for years." However, a reading of the warning labels indicates a clear need for heightened vigilance.

Labeling from Major Hair Color Manufacturers includes Tattoo Safety Warnings

*Warning: Temporary “black henna'' tattoos may increase your risk of allergy. Do not color your hair if: you have a rash on your face or sensitive irritated scalp; you have ever experienced any reaction after coloring your hair; you have had any reaction to a black henna tattoo in the past. Do not apply to mustache; avoid contact with eyes and do not use to dye eyelashes.(Excerpt from box label, ion™ Color Brilliance™, intensive shine™, PPD Free Demi Permanent Crème Hair Color, 305448, Dark Natural Brown, 3N–3.0)IMPORTANT SAFETY WARNINGS: Hair color products may cause allergic reactions, which in rare cases can be severe. Tattoos may increase the risk of allergy to this product.DO NOT USEthis product on clients who have experienced any reaction to hair color products or have sensitive, irritated or damaged scalp. In these cases, do not conduct the skin allergy test and consult a doctor before using any hair color product. Hair color should never be used for dyeing eyebrows or eyelashes, as severe inflammation of the eye or even blindness may result. .. . Wear suitable gloves. . . Hair color is manufactured and sold under the provisions of the U.S. Food, Drug and Cosmetic Act, which requires preliminary skin testing before all applications.(Excerpt from box label, printed on the inside of the box, Clairol Professional®, Soy4Plex liquicolor permanente, Gray Busters 5NN, Lightest Rich Neutral Brown, 320799, Permanent Haircolor)CAUTION: . . . Temporary ''black henna” tattoos may increase your risk of allergy. Do not color your hair if: you have a rash on your face or sensitive, irritated and damaged scalp; you have ever experienced any reaction after coloring your hair; you have ever experienced any reaction to a temporary ''black henna'' tattoo in the past. . . Do not apply to mustache. Do not use to dye eyelashes or eyebrows. To do so, may cause blindness . . . This product contains ingredients that may cause skin irritation on certain individuals and a preliminary test according to the accompanying directions should first be made. (box label)

CAUTION: . . . May contain: ammonia, phenylenediamines, toluenediamines, resorcinol. . . Ingredients may cause an allergic reaction. Wear suitable gloves.HYPERSENSITIVITY AND PATCH TEST INSTRUCTIONS: PRELIMINARY SKIN TEST. It is recognized that some persons are allergic to certain foods, drugs, cosmetics, etc. Some may also be hypersensitive to hair coloring products. These allergies can sometimes develop suddenly, even when prior exposure wasn't a problem. An easy way to detect such hypersensitivity is by performing a patch test.IMPORTANT INFORMATION . . . DON’TS: Do not color your hair if: - You have a rash on your face or sensitive, irritated and damaged scalp - You have ever experienced any reaction after coloring your hair - You have ever experienced any reaction to a temporary “black henna” tattoo in the pastBlack henna tattoos may increase your risk of allergy to this product. (box insert)

Cosmetology professionals should respond with hypervigilance, beginning with the client consultation. They should make sure to include (and indeed, emphasize) inquiries about tattoos, previous reactions to hair color products and skin or scalp sensitivities. Importantly, if they decide to continue with the product application they must emphasize safety procedures, for example; wearing gloves,for example, especially if the professional has a tattoo. Home hair color consumers should carefully read and follow hair color product safety warnings and instructions especially if they have a tattoo.

PPD (p-phenylenediamine) is the “black” in black henna tattoos. This ingredient and related compounds such as PTD (p-toluenediamine) can cause dangerous skin reactions or can sensitizeindividuals to hair dyes containing PPD or its chemical cousins.(Sensitization increases a person's responsiveness upon repeated exposure to the stimulus.) (11) Danger May Be Lurking"Is it possible that a tattoo or hair color can lead to a later reaction from the original contact with your skin or hair or scalp, even in subsequent months or years?" Most definitely “Yes.” Adding even more complexity, the combination of interactions has a latency factor that may provide a surprise. Just because a given procedure goes seemingly without event, it does not mean that a reaction won't manifest later.

Hair coloring is accomplished by putting a dye onto, or into, your hair so the coloring product contacts the scalp and /or the internal/external structure of the hair. (A dye that goes “into” your hair is absorbed into the hair shaft itself and comes into contact with your scalp.) Tattoo application is accomplished by injecting a dye into your skin or by making a temporary painting on the surface of your skin. If you have had a prior reaction to tattoo ink and/or black henna, you could also react to PPD or a related chemical in hair dye. It is also possible for tattoo ink to sensitize your skin to later application of hair color containing PPD or a related chemical and thereby trigger an allergic reaction. This can occur sometime after the original application of hair color or the tattoo. The reaction can range from mild to very severe. (11)

Misconceptions About Henna Tattoos

The established risks of the interactions of dyes in the body are multi-faceted. The interactions can include tattoos, henna and temporary tattoos.

To create popular henna or temporary henna tattoos, so called "black henna" is often used in place of traditional henna. Inks marketed as black henna depend on ingredients other than henna—commonly PPD—to generate the sought after black color and a longer lasting tattoo. Despite providing the desired effects, the use of black henna is potentially harmful. (1) (3) (4) (12) (14) In the proverbial nutshell: Henna will not produce a color other than reddish-brown. The black color produced by so called black henna has little or nothing to do with the presence of henna and directly results from the synthetic chemical PPD or its chemical cousins.

Many promote henna tattoos as a safer and/or more natural alternative to traditional tattoo inking. This is a misconception.

Henna is a reddish-brown coloring made from a flowering plant that grows in tropical and subtropical regions of Africa and Asia. Since the Bronze Age, people have used dried henna ground into a paste to dye skin, hair and fingernails. This decoration—sometimes known as “mehndi”—is still used today around the world to decorate the skin. Henna is sometimes promoted as a “natural” alternative to artificial chemical dyes, but while allergic reactions to “pure” henna are said to be very rare, reactions are possible. Despite the popularity of henna tattoos in the U.S., the FDA has not approved henna as an ingredient in temporary tattoos. (8)​Sometimes a tattoo artist will use PPD-containing tattoo ink or a product labeled as “black henna ink” that contains PPD or another, related compound that is also used in hair dyes. This practice is not allowed by Food and Drug Administration (FDA) regulations. The FDA does not allow PPD or any of the dye intermediates used in oxidation hair dyes to be used in cosmetics other than hair dyes, and particularly not in cosmetics intended for application to the skin. (13)

Tattooing and Body Art—State Laws and Regulations

As the popularity of both permanent and temporary body art grows, state laws have struggled to keep pace with the new art forms. Almost every state has statutes addressing some aspect of body art. State legislatures have had to amend their body art laws to ensure that these arts are practiced safely and that minors are protected. They also need to ensure that body art laws are not in conflict with the statutes regulating other certified professionals such as dentists, ophthalmologists and cosmetologists. Two sources on state laws are presented here: ​National Conference of State Legislatures (NCSL), table of state laws on tattooing and body piercing, http://www.ncsl.org/research/health/tattooing-and-body-piercing.aspx.​Centers for Disease Control and Prevention, Workplace Safety and Health Topics, body art regulations by state, http://www.cdc.gov/niosh/topics/body_art/stateRegs.html.

RECOMMENDATIONS​Cosmetologists andestheticians should respond to safety concerns related to the application of hair dye to a tattooed individual with hypervigilanceduring the client consultation and scrupulously adhere to product warnings, cautions and instructions. In particular, practitioners should ask specifically ask if the client has had a tattoo—anywhere—and if so inform the client of the possible risks of a color service. These risks include allergic reactions and/or possible sensitization. The question as to whether the hair color client has been previously tattooed anywhere should not under any circumstances be skipped, missed and this includes so called temporary henna tattoo. Most people consider temporary tattoos to be harmless, which they are not.In the same way, that the tattooist should inquire as to the clients wearing of hair color a proper inform of the associated risks. (10) (11) (12) (13)

​FDA.gov allergic reaction to temporary tattoo

The cosmetology professional should also ask if the client has ever had any reaction to hair color products or has a sensitive, irritated or damaged scalp. In these cases, the professional should NOT conduct the skin allergy or patch test, and should advise the client to consult a doctor before using any hair color product.​When no reactions to hair color products or current skin sensitivities have been revealed during the client consultation, a patch test should be administered 48 hours before any hair color service, or as instructed on the product package. Cosmetologists who have tattoos should take special care to wear gloves when applying and processing any hair color, and they should take the steps necessary to avoid direct contact with the product at all times. (11) (12) (13)

Estheticians in the U.S. should not use foreign-manufactured eyelash and eyebrow dyes containing PPD on any client, especially those who have tattoos. PPD is not approved in the U.S. for use in cosmetic products intended for use on the skin or in eyelash or eyebrow dyes. Indeed, in the U.S. there are no products approved for permanently coloring eyelashes or eyebrows. (10)Cosmetic tattoo professionals should avoid the use of products that do not conform to FDA regulations and forewarn customers of possible complications if the customer plans to color his or her hair in future. (12) (13)

Tattoo professionals and technicians should not alter purchased inks and not use inks or products that do not conform to FDA regulations. They should warn customers of possible complications from tattoos, particularly temporary henna tattoos, if the customer plans to subsequently use professional hair color services or retail products for at-home hair coloring. (12) (13)Consumers who have a tattoo and who intend to color their own hair at home should make sure to perform a patch test of the hair color product to be used 48 hours before application, following the test instructions on the product package.​All practitioners either tattoo art or cosmetology should know the signs of allergic reaction to the products they use, which may include fever, rash, redness, swelling, weeping wounds, blemishes or excessive pain at, or remote to, the site of contact. If the client experiences any of these signs, advise the client to seek medical attention immediately. (11) (12) (13)

Outlook

As the prevalence of hair coloring and tattoos grows, so too do the related health dangers.

It is crucial that all practitioners and both beauty salon and tattoo parlor professionals get current on best practices for the safety of all involved in these procedures. It cannot be stressed enough that all training certifications must cover these safety warnings and that protocols should become the standard operating procedure.

Of related note but not within the purview of this paper, there can be very real legal liability of beauty salon and tattoo parlor owners for injuries that occur due to lack of adherence to safety recommendations.